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Responsible Party Agreement

Download the form in Microsoft Word format

Download the form in PDF format

Or fill out and submit the form online:

INNOVATIVE PHARMACEUTICAL PACKAGING CORP
703 GINESI DRIVE, MORGANVILLE, NJ 07751
Phone (732) 617-8686 Fax (732) 617-8321

RESPONSIBLE PARTY AGREEMENT

Personal Information:

Community Name

Name of Resident

Date of Birth

Check One:

Male | Female

Social Security
Number

Responsible Party Name

Responsible Party Address

City

State

Zip

Home Phone

Employment Phone

Relationship to Resident

Financial Information:

Private Pay Private Insurance Medicaid Pending Medicaid - Applied
Medicare D

You must provide a photocopy of the front & back of your prescription insurance card.

I UNDERSTAND AND ACCEPT THE FOLLOWING TERMS AND CONDITIONS:

  • I agree that community personnel are authorized to order, purchase and charge on behalf of the above resident.
  • I agree to provide the pharmacy with a photocopy of the front and back of the insurance cards used for prescription coverage.
  • I agree to notify the pharmacy of any future changes in prescription coverage.
  • I agree that any medication that has been discontinued or expired will be destroyed by the Facility and /or Pharmacy.
  • I agree to pay all charges incurred by myself or the above named resident not paid for by third party payees, including Medicaid.
  • I agree in order for the account to remain active, the account must remain current.
  • I agree to pay all costs of collection including court costs and attorney's fees, if necessary, in order to collect any and all delinquent balances.
  • I understand that the medications furnished to the above named resident are not packaged in child-proof containers.

    		•

    Responsible Party/Guarantor

    Date

    As a recurring transaction,
    you may charge my Visa

    Or Mastercard

    Account No.

    Expiration Date

    3-digit code on back of card (CVA#)

    Signature

    Date